Comprehensive orthodontic approach of the excessive gingival smile Mona Ghoussoub. August 12th 2021. Episode 123

Join me as I summarise Mona Ghoussoub’s lecture looking at the excessive gingival display (EGD).

Mona looked at the diagnosis and treatment of EGD, with a focus on aetiology leading to treatment method, effect of age, and input of multidisciplinary care for appropriate cases.

Definition Kokich 1999, Machado 2014

• Negative effects = 4mm + gingival display

Diagnosis identifying aetilogy

• Medical history – medication
• Facial analysis – VME
• Lip analysis –
  • short lip: lip length 20-22mm
  • hypermobility of elevator muscles
  • Lip line
  • Age increases = greater increase in mandibular incisor show, after 40 years of age, great mandibular incisor show then maxillary incisor show
  • Location, anterior or posterior increase
• Dental analysis – Short crowns = crown height
  • Maxillary incisor width : height = 80%
  • Centreline Coincident = well intercuspation
• Periodontal examination
  • Altered passive eruption
    • Pocket without pathology

Treatment approach

Early treatment

• Medical ENT allergology
  • Excessive gingival show age 7-8 years
  • Nasal obstruction causes decrease in lip closing force Sabashi 2011
  • Detect and refer ENT if suspect nasal obstruction
    • Dark eyes
    • Flat cheeks
    • Increase LAFH
  • Orthodontic – prevention
    • Utility arch
      • Intrusion upper anterior teeth
      • 4 brackets and molar bands
      • Retain with 2 layers of Essix + brass wire – for rigidity

Late treatment

• Orthodontic
  • Alignment
    • 2 occlusal planes in maxilla in 2 div 2, posterior higher, anterior lower
      • Straight wire – reciprocal effects
        • Intrusion of anterior teeth
        • Extrusion of posterior teeth
      • Expansion
        • RME
          • Posterior expansion = gingival position moves upwards
            • When constricted, greater posterior gingival show

• Intrusion
  • Ricketts / Burstone 3 piece intrusion arch
  • Headgear – J hook intrude upper anterior teeth
  • TAD placement for anterior intrusion
    • UR1-UL1 labial
    • Powerchain archwire to TAD
  • TAD for posterior intrusion
    • U5-U6 region buccal
    • Direct retraction U3- TAD
      • Below centre of rotation = posterior intrusion

• MDT
  • Periodontics
    • Gingivectomy – passive over-eruption of dentition
      • Ideal where tooth width:height ratio increased
    • Guided Tissue Regeneration for VME
      • Stable after 1 year
      • 40-60% improvement in excessive gingival growth, with crown lengthening
      • Bony cavity at anterior superior aspect of maxilla
        • Results in the lip raising higher
        • Bone augmented at the level of the Le-fort 1
        • Can be clinically simulated with cotton wool rolls in upper labial sulcus and taking photos
      • Orthognathic surgery
        • Decompensate
          • Maxillary impaction
        • Plastic surgery Pierre 2020
          • Short lip / mild VME = lip repositioning surgery Rubinstein 1973
            • Limit the smile muscle pull by reducing the depth of the upper vestibule– zygomaticus minor, levator Angulo, orbicularis oris, levator labil superior Tawfik 2018
            • Conservative when compared to OGN
            • Technique
              • Split thickness flap – expose connective tissue
              • Advance mucosa and suture at mucogingival junction
            • Limited studies
            • Overcorrect as some relapse expected
            • Systematic review improve EGD 3-4mm Tawfik 2018
          • Hypermobile lip – Botox Cengiz 2020
            • Reduce muscle activity – levator labil superios LLSAN, zygomaticus minor / major, risorius muscle
            • NOT classified as an alternate treatment for EGD
              • Use = indication for patient outcomes possible for lip reposition
            • Temporary effects – relapse at 6 months
            • Problems
              • Dose related results
              • Excessive upper lip ptorsis
              • Too little – not achieve desired result
              • Smile effected if erroneous
                • = require expert to use

Conclusion

• Not all patients are the same
• Age / skeletal / gingival aetiology
• Explore differential diagnosis
• Treatment outcome – inter-incisal angle for stability for intrusion
• Overcorrect intrusion
• Individualise retention